Analysis Collision Avoidance ATLANTIC HURON Good seamanship practice dictates that speed be adjusted according to restrictions such as prevailing conditions of light or darkness, sea room, traffic, weather conditions, and navigational aids available. Given the circumstances of the occurrence, a reduction in speed could have provided the navigating officer more time to resolve the situation and avoid passing in the narrow constraints of the channel, more so as he believed that the LADY SANDALS was a large vessel. The course alteration to starboard and off the recommended 302T course line by the LADY SANDALS did not place it as close as was practicable to the (starboard side) outer limit of the recommended route where there was sufficient sea room to manoeuvre. The OOW was concerned about sufficient sea room for a port-to-port passage and he did not use the VHF radiotelephone to full advantage to seek additional information or make use of the ship's whistle to indicate such doubt. Instead, the OOW made an assumption that culminated in the large vessel ATLANTIC HURON keeping out of the way of the small vessel LADYSANDALS. GRIFFON The OOW was aware that the ATLANTIC HURON would be passing by within three cables, but he did not take any action to attract its attention until it was just under two cables away. Also, the radiotelephone was not used to communicate with the ATLANTIC HURON. As individuals are exposed to a situation repeatedly and do not experience direct negative feedback, their perception of the associated risk decreases. This is true of both high and low risk situations. The navigating personnel of the GRIFFON had previously tracked other vessels passing two to four cables off their anchored position. Navigating personnel continued to monitor passing vessels and had become accustomed to such close passages to the extent that it was expected that a vessel would pass close by. Furthermore, because their vessel was lit up at night, the bridge team assumed that transiting vessels would take appropriate action to avoid coming dangerously close to the GRIFFON. Anchoring Near Shipping Routes Owing to the nature of the work, CCG vessels remain in close proximity to aids to navigation. Factors influencing the master's decision to anchor in this location included the following: The forecasted winds, which were light to moderate northeasterly winds backing to northwesterly, would keep the vessel away from the shallow water to the west. Being close to the work site permits timely action to be taken in the event of an emergency relating to the work boat or should the weather become foul. The anchored position of the GRIFFON was four cables from the recommended course line printed on the chart, and a SCURIT call was not broadcast by the vessel.[11] A NOTSHIP was neither initiated by the vessel nor broadcast by MCTS to warn transiting vessels of the presence of the GRIFFON. Consequently, the ATLANTIC HURON and the LADYSANDALS were unaware of information necessary to the safety of vessels operating in the area. Detection by Other Vessels Other vessels transiting the passage saw the trace of the target of Pelee Passage light on the radar but did not see the trace of a target indicating the presence of the GRIFFON__with one exception. The CSL NIAGARA saw an unclear trace of a target in the vicinity of Pelee Passage light but did not see a vessel's lights and thought it was an abnormal RACON signal. The vessel contacted MCTS in Sarnia which confirmed that the GRIFFON was near the light. The ability of the radar to discriminate between two objects which are on the same bearing depends on the strength of echoes, which, in turn, depends on the material of construction, and target aspect, position, size, and shape. Two targets, when close together, can be mistaken for one target. Pelee Passage light has a RACON fitted on top of the light structure. The RACON emits a signal showing the relative direction to a vessel when it detects the presence of the vessel's radar pulse. The RACON at Pelee Passage light emits a Morse Code M (- -) signal which would appear on the side opposite from the RACON as seen by an approaching vessel. The radar return of a vessel can be masked if the position of that vessel coincides with the plume of the RACON signal. There is also a period of time in which the RACON does not respond to allow radar targets which may be masked by the plume of the RACON signal to be detected. The RACON at Pelee Passage does not respond for nine seconds over a 30-second period. As well, the RACON can be desensitized by the radar of a nearby vessel which could, in fact, further reduce, from 42 to 6 seconds, the amount of time normally made available in one minute for the RACON's active signal. It is likely that the close proximity of the GRIFFON to a large light structure resulted in two targets being mistaken for one. The plume of the RACON signal may also have partially masked the radar return from the GRIFFON as observed on board the ATLANTIC HURON. As a result of the reduction of the time available for the RACON's active signal, bridge teams on vessels which are farther away from the RACON would need to pay particular attention to radar. The detection of the GRIFFON by other vessels was therefore hampered by its proximity to a large light structure and the light's RACON signal. Confirmation Bias Once an individual has developed a working model of a situation, information is incorporated selectively and will favour that which confirms the individual's mental model. Information which does not match the mental model may be rationalized into the model or discounted altogether. In essence, an individual will use information that he or she expects to see and may not incorporate information which is present but does not fit the model.[12] In such situations, barring strong intervention, be it by way of a strong cue or by outside intervention, the individual may experience difficulty in realigning the model to correspond with the situation. Given that the OOW of the ATLANTIC HURON had no prior indication that the GRIFFON was anchored near the tower and the target of the GRIFFON was not evident on the radar, the mental model of the OOW of the ATLANTIC HURON likely did not include the vessel's presence. Even though the OOW detected lights in the vicinity of the light tower, they did not fit his mental model and taken with the other cues, were not sufficient to alter his mental model. It is likely that the OOW of the ATLANTIC HURON did not realize the inaccuracies of his mental model until the LADY SANDALS had passed and the danger of collision with that vessel had receded. The rapidly looming lights of the GRIFFON then most probably captured his attention and led to the initiation of emergency action. Reporting to Marine Communications and Traffic Services As reporting to MCTS was not mandatory for this area, MCTS did not volunteer traffic information to vessels unless specifically requested to do so. Such was the case with the CSL NIAGARA. Further, when the RESERVE issued a SCURIT call, it was not informed of the presence of the GRIFFON. The absence of all pertinent safety information to vessels may result in decision-making based on incomplete information thereby jeopardizing the safety of vessels operating in such areas. Pelee Passage is an area in which MCTS reporting is voluntary, all commercial vessels may not participate in it, and there is no radar coverage. Consequently under the current regime, the reliability, completeness and accuracy of information provided by MCTS to vessels cannot be assured. The introduction of AIS will enhance safety through real-time vessel-to-vessel communication and provide valuable information such as vessel name, position, course, and speed, to other vessels and MCTS. Had AIS been fitted aboard the vessels in this occurrence, more accurate and more timely information (relative to that obtained from the ARPA) on which to base action would have been available. ECDIS and ECS Training Electronic chart display and information systems (ECDIS) and ECS are rapidly being embraced in the maritime community as they offer numerous benefits compared to conventional navigation systems. These include the continuous real-time display of a ship's position, various predictive functions and the potential for radar overlay. Unlike printed charts, ECDIS and ECS are complex computer-based information systems that can provide valuable new capabilities to bridge crews. Like most navigational aids, these integrated systems also have limitations, an appreciation of which is essential to derive optimal benefit from their use. The compelling nature of systems such as ECDIS and ECS is a serious drawback which has been identified in research on automation.[13] Because of the very high fidelity representations of the world associated with an ECDIS or ECS system, operators may selectively use the apparently precise information, placing less emphasis on other real-world cues, such as visual cues. In this occurrence, while the OOW had noticed some lights in the vicinity of the light structure, the presence of the GRIFFON was not evident on the radar overlay. Given the immediate goal of passing the LADY SANDALS, the OOW focussed on the apparently precise representation of the area provided by the ECS system, and did not appreciate the variance between its representation and the visual cues. The international community, through the IMO, has recognized the need for ECDIS training to ensure correct operation and users' appreciation of system limitations. The IMO has developed a model course for ECDIS, as well as a handbook[14] that provides guidance on the development and implementation of such a course. Transport Canada syllabus and training requirements are available, as laid out in TP 4958, for the purpose of approving ECDIS training courses. This follows the training syllabus approved by the IMO. While this training is available at Canadian marine institutions, there are, however, no Canadian or international requirements that this training be taken in order to be issued a certificate of competency or associated endorsement of certificate pursuant to the provisions of the 1995 amendments to the Annex to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978 (STCW 95). ECS provides a large number of navigational functions, including predictive displays which can provide advance warning in the form of audible and visual alarms of impending dangerous situations. There is a fine balance between providing warning alarms and generating nuisance alarms. Numerous cases are on record where systems which excessively generate nuisance alarms have been deactivated, and as such were unable to provide a warning. On board the ATLANTIC HURON, the ECS audible alarm was previously deactivated because of the unacceptable number of nuisance alarms generated. The OOW had not received formal training in the use of ECS, which would have enabled him to better set up the ECS system, and would have thereby reduced the number of nuisance alarms and maximized the opportunity to detect impending dangers. Use of Audible Alarms During Emergency Situations Alarms are used to indicate the presence of an abnormal condition, malfunction, or other dangerous situation requiring attention. They may use audible and/or visual means at the site and at a central position, such as the navigating bridge, to draw attention to the situation. Typically, vessels have various audible alarms on the navigating bridge and, to be effective, each audible alarm should be clearly heard above the ambient noise levels of normal operations. Ideally, these audible alarms should not interfere with the safe navigation of the vessel nor hinder operations during emergency situations. Following the striking, the master of the ATLANTIC HURON called the GRIFFON on VHF radiotelephone channel 16 several times, but there was no reply. When the GRIFFON was struck, a CO2 siren-type alarm sounded on the bridge, the intensity of which prevented communications on the bridge and between the bridge team and the emergency teams and muster stations. The alarm was activated by the release of CO2 gas in the forward boatswain stores. The alarm sounded for approximately five minutes before the reset switch was located and the alarm was silenced. Its reset switch was labelled with a number only and was located among other breaker switches in a panel located forward of the chart table. None of the bridge team members, other than the chief officer, was aware of the location of the reset switch. Activation of Emergency Alarms The ability to locate and operate an alarm during an emergency situation is imperative for the safety of the crew of the vessel. Delays in alerting the crew may preempt the taking of appropriate action and may result in serious injury. There have been other occurrences where the bridge crew was unable to activate alarms in a timely manner.[15] Given the normal tendency of those involved to attempt to extricate themselves from a developing situation, activation of alarms is normally left as a last measure once it is apparent that the situation is critical. At this point in the emergency, crews may experience difficulty in locating and identifying the appropriate alarms due to the heightened level of stress and anxiety associated with the situation. The difficulty can be further exacerbated in nighttime scenarios, where the perception of visual cues may be less likely. On board the ATLANTIC HURON and the GRIFFON, the switches for the general alarm, public address system, and whistle are unlit. During an anchor watch or when under way, switches and labels cannot be seen easily at night by bridge team members. It is common practice on many vessels for the crew to make use of a flashlight. The difficulty experienced by the OOWs on the ATLANTIC HURON and the GRIFFON in locating and activating the general alarms was likely due to the high level of stress associated with the emergency situation, exacerbated by nighttime conditions. The probability of successful activation of safety critical switches can be improved through a number of options ranging from training and focussing on emergency drills to applying ergonomic design principles (such as location, grouping, coding, and lighting), which take into account the impact of performance shaping factors such as stress and the environment. Effect of Underkeel Clearance on Manoeuvrability of Vessel As a vessel moves ahead in a restricted shallow channel, the flow of water under the hull is accelerated and causes a reduction in pressure, such that the vessel settles deeper than its static mean draught. This phenomenon is known as squat and depends on the vessel's speed, the ratio of its static draught to channel depth, and the cross sectional areas of the hull and the channel. When the speed (through the water) is such that some underkeel clearance (UKC) is retained and bottom contact is not made, the hydrodynamic effects of the squatting condition continue to affect the vessel's trim and have a detrimental effect on its handling characteristics. These detrimental effects include increased wave making--especially at the forward end, which generally causes the vessel to become sluggish and slower to respond when manoeuvring. There was a tendency for the ATLANTIC HURON to squat during the voyage as a result of proceeding at full speed with a low UKC. The situation would have been further exacerbated by its list to starboard. The reluctance of the vessel to swing to starboard when avoiding the LADY SANDALS, as well as the shuddering when full helm was applied, are consistent with the reduction in the manoeuvrability of a vessel when experiencing squat, and particularly when entering shallower waters. Findings Findings as to Causes and Contributing Factors The detection of the GRIFFON by other vessels was hampered by its proximity to a large light structure and the light's RACON signal. The detection of the GRIFFON was further exacerbated by assumptions of the OOW of the ATLANTIC HURON that no vessel would be at anchor, at that location, at night. The VHF radiotelephone was not used to advantage by either the ATLANTIC HURON to obtain pertinent information from the approaching vessel or by the GRIFFON to broadcast a SCURIT message. No NOTSHIP was initiated by the GRIFFON to inform other vessels of its location. The LADY SANDALS did not keep as close as was practicable to the starboard outer limit of the recommended route, where there was sufficient room for it to manoeuvre. The OOW of the ATLANTIC HURON did not fully appreciate that his vessel was experiencing squat which reduced the manoeuvrability of the vessel. Findings as to Risk Non-illuminated switches for emergency alarms on vessel bridges are more difficult to locate during emergency situations under night conditions, increasing the risk to persons aboard the vessels. The absence of feedback to the person initiating the general alarm or making public address announcements from the navigating bridge precludes confirmation of the successful transmission of critical information essential for the safety of ship's complement. The OOW of the ATLANTIC HURON had not received formal training in the use of ECS, which would have enabled him to better set up the ECS system, and would have thereby reduced the number of nuisance alarms and maximized the opportunity to detect impending dangers. Safety Concerns Training on the Use of Electronic Chart Systems for Navigation This occurrence highlights the importance of the need for formal training on the use of technologies such as ECDIS/ECS. These technologies and their use is increasing within the industry to further navigation safety and reduce navigation workload. Such training would allow crews to appreciate the limitations of the equipment and take full advantage of the technology. Without it, decisions made will be based on incomplete information. The Board is concerned that formal trainin1g is not keeping pace with changing technology. The absence of such training exposes vessels to risk of accidents thereby compromising the safety of their crews. Communications Between Vessels The timely exchange of pertinent information between vessels is an important consideration in contributing to the safe navigation of a vessel. Without it, the time available to permit crews to better appreciate a close-quarters or collision situation is reduced. Furthermore, as demonstrated by this occurrence, the lack of an exchange of information can result in unsafe decision making based on insufficient information. Inadequate communications, as was revealed in this investigation, is not limited to this accident; the TSB has conducted several investigations into marine accidents in which inadequate communication was noted, including the following: For example, in the investigation into the 1994 collision between the TARANTAU and the RESERVE, the collision occurred due to a lack of communication by both vessels. Neither master called the other to advise him of his actions; each master thought that he was aware of the other's actions and intentions. Adequate communications ensure that crews share a common understanding of a situation and of each party's intentions. The Board is concerned that without it, crews will continue to make decisions based on incomplete information thereby putting themselves and their vessels unnecessarily at risk.